Violence Against Healthcare: A Public Health Issue beyond Conflict Settings

On May 3, 2016, the UN Security Council unanimously adopted Resolution 2286, which obliged Member States to take specific actions to end violence against healthcare.¹ However, the review of violence against healthcare from 2016 to 2020 by the Safeguarding Health in Conflict Coalition highlighted the inaction of governments to effectively respond to the crisis.²

A 3-year analysis released in August 2021 by the WHO indicated that more than 700 healthcare workers and patients died (2,000 injured) as a result of attacks against health facilities since 2017.³ The report highlighted how one out of six incidents have led to a patient or health worker’s loss of life in 2020.³ In the last 5 years, health workers, including midwives and nurses, were also victims of sexual violence in or in the vicinity of hospitals in Afghanistan, Libya, Nigeria, Pakistan, Sudan, Democratic Republic of the Congo, and Central African Republic.²

The COVID-19 pandemic has made the risks even worse for doctors, nurses, and support staff, unfortunately. Data provided by the WHO report that 8–38% of health professionals worldwide are victims of physical violence at some point in their careers.³ Nonetheless, the pandemic has aggravated situations of violence against them. Specifically, COVID-19 has both exacerbated existing sources of violence and opened up new areas of confrontation between healthcare providers, patient families, and the general public.

According to the latest figures from the International Committee of the Red Cross (ICRC), 848 COVID-19-related violent incidents were recorded in 2020, and this is likely an underrepresentation of a much more widespread phenomenon.⁴ ICRC analysis showed that the vast majority of incidents were interpersonal violence in the community, including patients and their relatives assaulted healthcare workers. A striking example was provided from Naples, Italy, where a patient with COVID-19 symptoms spat at a doctor and a nurse after being told to wait. As a consequence, the entire ward was closed and the staff was sent to quarantine.⁴ Front-line health professionals are also vulnerable to the emotional impact of the pandemic due to long working hours, inadequate personal protective equipment, and the risk of contamination.^5,6

As emphasized by Bitencourt et al., Violence against health professionals affects their performance and, consequently, the care provided to patients and their families. Furthermore, suffering violence can trigger or exacerbate stress, anxiety, depression, and burnout in professionals and their families during the pandemic.⁷ Very similar evidence emerged from studies in China where front-line health professionals are at a high risk of having depression, anxiety, insomnia, distress, and stress, and this can be further aggravated when they are victims of violence at work.⁸ Violence at work in turn can lead to fear, decreased self-confidence, sleep disorders, irritability, and panic syndrome.⁹

In response to rises in COVID-19-related attacks against healthcare, some countries have taken action. In Algeria, for instance, the penal code was amended to increase protection for healthcare workers against attacks and to punish individuals who damage health facilities. In the United Kingdom, the police, crime, sentencing, and courts bill increased the maximum penalty from 12 months to 2 years in prison for anyone who assaults an emergency worker. This followed evidence of a 30% increase (total of 3,569 individuals) from 2016 to 2017 in ambulance staff physically assaulted.¹⁰ Additionally, India amended its emergency epidemic law to define attacks on healthcare workers punishable by up to 7 years in prison while Sudan announced the creation of a dedicated police force to protect healthcare workers during the pandemic.¹⁰

Measures taken by countries represent a good practical way to counteract this crisis within COVID-19. However, we stress the importance of primary prevention with the use of communication: social media and other communication channels are fundamentally important to combat violence against health professionals, both to inform the population with quality data on the disease and to disseminate campaigns to prevent these acts. A very recent systematic review on the effectiveness of interventions to address violence in healthcare settings has indicated that a positive impact heavily relies upon multicomponent interventions with involvement of all stakeholders.¹¹ A series of combined promising strategies have been adopted in different settings, and include actions like the implementation of alert system to identify high-risk patients upon admission, meetings with all stakeholders to revise workplace violence policies, staff training for prevention of workplace violence, as well as training for healthcare workers to de-escalate and manage violence (such as the one just launched by ICRC in Pakistan¹²).

The encouraging results of these combined approaches further substantiate the recommendations made by the WHO, which claims that training and interventions must go beyond the individual level and include organizational policies and work environment changes.¹³